In June, a series of problems with brachytherapy for prostate cancer at a Veterans Administration (VA) hospital in Philadelphia became front-page news in the New York Times,¹ as well as the Philadelphia Inquirer.² This series followed on the heels of congressional hearings on reports of widespread contamination of endoscopes alleged to have exposed thousands of patients to possible serious infections at VA medical centers in Tennessee, Georgia, and Florida.³

Ironically, the Veterans Health Administration (VHA) is renowned for its quality and safety programs. VHA developed strong, centralized, quality assurance programs, a patient safety center, and a detailed reporting system. If major problems can happen in a model system like VHA, is there any hope for facilities in Pennsylvania?

I propose that there are valuable lessons to be learned from the recent VA experiences for much smaller systems and facilities, as follows:

1. The potential for catastrophe is ever present and requires constant effort and vigilance for areas of weakness, even in the best healthcare delivery systems.
2. VHA is a highly centralized system with high levels of accountability to Congress for the healthcare of our veterans. When VHA detects a problem in the system and thoroughly investigates, the action plan has the potential to improve the care for a large number of patients. The Pennsylvania Patient Safety Authority has shown that reporting from a large number of small systems or facilities can also identify problems that, when investigated, can improve the care for large numbers of patients beyond a single experience at a single hospital.
3. Standardization across an entire system can produce a uniform, reliable result, but if not standardized around best practice, it can produce systematic, rather than sporadic, problems. Processes and outcomes need continued monitoring to make sure that the best practices are followed and result in the optimal outcomes.
4. Part of the problem with the brachytherapy, as reported in the papers, was the lack of compliance with existing protocols. For instance, it was reported that the program did not require the proceduralist to obtain radiographic images to confirm the location of the radioactive pellets and that the calculations were not done to determine the doses delivered.^2,4 Compliance with protocols needs to be verified and periodically monitored.

Patient safety is not a task. It is an integral part of the reliable delivery of quality healthcare and of quality improvement. Monitoring best practices, compliance with those practices, and outcomes is essential to quality improvement.

Notes

1. Bogdanich W. At V.A. hospital, a rogue cancer unit [online]. N Y Times 2009 Jun 21 [cited 2009 Jul 15]. Available from Internet: http://www.nytimes.com/2009/06/21/health/
   21radiation.html?_r=1&scp= 1&sq=a%20rogue%20cancer%20unit&st=cse.
2. Goldstein J. Feds see wider woes in VA’s cancer errors [online]. Phila Inquirer 2009 Jun 21 [cited 2009 Jul 15]. Available from Internet: http://www.philly.com/inquirer/health_science/daily/20090621_Feds_see_wider_
   woes_in_VA_s_cancer_errors.html.
3. Department of Veterans Affairs (VA), Office of Inspector General. Healthcare inspection: use and reprocessing of flexible fiberoptic endoscopes at VA medical facilities. Report No. 09-01784-146. Washington (DC): VA Office of Inspector General; 2009 Jun 16.
4. McCullough M, Goldstein J. VA radiation errors laid to offline computer [online]. Phila Inquirer 2009 Jul 19 [cited 2009 Jul 20]. Available from Internet: http://www.philly.com/philly/news/homepage/20090719_VA_radiation_errors_laid_
   to_offline_computer.html.

John R. Clarke, MD
Editor, Pennsylvania Patient Safety Advisory
Clinical Director, Pennsylvania Patient Safety Authority
Professor of Surgery, Drexel University